Product Details
Pancrease MT4
Pancrelipase Equivalent To Lipase + Amylase + Protease4000 + 12000 + 12000 USP Units
Capsule with Enteric-Coated Microspheres
DIN/PIN/NPN
00789445
Manufacturer
Vivus Inc.
Formulary Listing Date
1996-10-01
Unit Price
0.7274
Amount MOH Pays
0.7274
Coverage Status
Limited Use Product
ODB Formulary Therapeutic Classification
Therapeutic Note
NO
ATC Code
A09AA02
Interchangeable Products
NOLU Clinical Criteria
| LU Code | Auth. Period | Clinical Criteria |
|---|---|---|
| 124 | Indefinite | Replacement therapy for pancreatic insufficiency secondary to pancreatic surgery (resection). |
| 125 | Indefinite | Replacement therapy for pancreatic insufficiency due to chronic pancreatitis. |
| 126 | Indefinite | Replacement therapy for pancreatic insufficiency due to carcinoma of the pancreas. |